Neurology, Cognition, Cognitive Screenings and Audiology, Part 1

Abstract

Welcome to the first installment of our new column, Perspectives With Dr. Beck. With career experience spanning the roles of Audiology program director and adjunct professor, private practice co-founder, Editor-in-Chief, society web content editor, and industry manufacturer consultant, Dr. Douglas L. Beck brings his unique wealth of insight to The Hearing Journal through interviews with leading industry experts and in-depth articles exploring audiology’s most significant challenges and opportunities.www.shutterstock.com. Perspectives With Dr. Beck, neurology, cognition, cognitive screening, James Galvin.James E. Galvin, MD, MPH. Perspectives With Dr. Beck, neurology, cognition, cognitive screening, James Galvin.Results from Johns Hopkins University’s Aging and Cognitive Health Evaluation in Elders (ACHIEVE) study linking the use of hearing aids to a more slowed cognitive decline were recently published in The Lancet, leaving audiologists grappling with how involved they should be in their patients’ cognitive screenings. Dr. Beck speaks with James E. Galvin, MD, MPH, in a two-part interview covering the nuanced topic of audiology’s relationship with cognition. Dr. Galvin is the Alexandria and Bernard Schoninger Endowed Chair in Memory Disorders and Professor of Neurology and Psychiatry & Behavioral Sciences at the University of Miami Miller School of Medicine. He is Founding Director of the Comprehensive Center for Brain Health, Director and Principal Investigator of the Lewy Body Dementia Research Center of Excellence, and Chief of the Division of Cognitive Neurology leading brain health and neurodegenerative disease research and clinical programs. Dr. Beck: Good morning, Jim. Thanks for meeting with me today. Dr. Galvin: Hi, Doug. Thanks for inviting me. Dr. Beck: Entirely my pleasure! By way of disclosure, I want to report that you and I met in 2022, before I retired as VP of Clinical Sciences at Cognivue, Inc. At that time you were an advisor on the Cognivue clinical advisory board, and I was always very interested in your thoughts on contemporary issues. Before we get into the clinical issues, where did you go to medical school? Dr. Galvin: I went to medical school at what is now Rutgers University, but when I attended it was called The University of Medicine and Dentistry of New Jersey – New Jersey Medical School in Newark, NJ. Dr. Beck: And because you’re a professor of both neurology and psychiatry at the University of Miami Miller School of Medicine, it seems I should ask…did you do a fellowship in both disciplines, neurology and psychiatry? How does that work? Dr. Galvin: The way it works is the Board is the American Board of Psychiatry and Neurology is the one board for both disciplines. It can be confusing, but generally, the practitioner becomes Board Certified in one discipline, and for me that’s neurology, although members can do a residency in neurology or psychiatry or they can be “double-boarded” and do both neuro-psychiatry, but again, most partitioners choose one discipline. Dr. Beck: Thanks, Jim. As we’re progressing through this fascinating decade, an increasing number of hearing care professionals (HCPs) are referring to, and working with, physicians regarding mild cognitive impairment (MCI) and dementia. Let’s start with how many neurologists are in the USA? Dr. Galvin: The census varies with the source, but I would guess about 14-15 thousand, and clearly that’s nowhere near enough! And just for comparison, there are probably five or six times as many psychiatrists. The NIH (2021) reports (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7884982/) that although the number of neurologists varies by region, the prevalence of neurologic conditions across the country remains fairly constant, and there is an increasing need for more neurologists. They also note that as the small supply of neurologists has slightly increased (only some 2% of physicians are neurologists) more attention has been focused on dementia, pain, and stroke, while other areas seem to get less attention, including Parkinson’s disease and multiple sclerosis. And many of the areas with heightened attention are due to the increased life span and the aging of the population. Dr. Beck: Why do you think so few people go into neurology? Dr. Galvin: We’re a quirky bunch. Traditionally, neurologists were the doctors who knew everything but could do nothing about it. It was a very ‘cerebral’ discipline where we focused on the differential diagnosis, but we had few treatment options available to us. That has obviously changed over the past decade with many exciting and effective interventions for seizures, strokes, multiple sclerosis, peripheral neuropathies, and now also for Alzheimer’s disease. Also, neurology is a relatively low-reimbursement specialty, so that doesn’t help attract a lot of new talent! Dr. Beck: And of those neurologists who are practicing, what percentage address cognition, MCI, dementia, and cognitive screenings as their primary professional area? Dr. Galvin: Those specific areas are generally referred to as Cognitive and Behavioral Neurology, and as we just mentioned, these areas are experiencing some growth, but again the numbers are relatively small. Dr. Beck: The American Academy of Audiology (AAA) and the American Speech Language Hearing Association (ASHA) both state that cognitive screenings are within the Scope of Practice of audiology. As such, I’m curious as to whether you’ve seen direct referrals from audiologists, or do audiologists primarily refer their at-risk patients back to their PCPs? Dr. Galvin: My patients come from a large array of referral sources; most of my referrals come from Internal Medicine. I get referrals from other neurologists and psychiatrists, and I think you’d be surprised at how many patients simply ask Dr. Google what this or that might be, or what it might mean, and they self-refer. And as you would expect, we get referrals from ENT, Neurosurgery, General Surgery, and more, as they often recognize something is not quite right. Of the non-physician specialties, we get referrals from Occupational and Physical Therapy, too. Dr. Beck: So it seems Social Workers, Speech-Language Pathologists and Audiologists are referring their patients to the primary care doctor? Dr. Galvin: Yes, it looks that way from my practice. And as you know, depending on the way their insurance plans are structured, many patients can’t go directly to a neurologist without first seeing their primary care physician (PCPs) to obtain a referral. Dr. Beck: At which point does the PCP refer the patient to neurology? Dr. Galvin: That varies quite a bit. Some PCPs are content to diagnose, treat, and manage their patients across the spectrum of disease, others are not. Sometimes, the PCP has been successfully managing the patient, but suddenly the situation becomes more complicated, so they refer, and sometimes, the loved one or the family is simply pushing for a referral to a specialist. Dr. Beck: And so in all probability, more MCI and dementia patients are being managed by PCPs, than neurologists? Dr. Galvin: Yes, absolutely. This seems due to practice preferences and due to the sheer numbers of PCPs compared to neurologists. In some areas, the neurologist will only do the initial consultation and then send the patient back to the PCP for management. Dr. Beck: And how often do referred people come to you with a “non-normative” screening result, or a positive cognitive screening result? Dr. Galvin: That’s an interesting situation. We’ve done two different studies based on Electronic Health Records (EHRs). Turns out fewer than 25% of seniors have received their annual wellness visit, and to your specific question, actual cognitive screenings or formal diagnostic cognitive assessments are only done on some 25% of referred patients. It is possible some clinicians are doing screenings or diagnostic tests, and for some reason not reporting them, but from what we can see in the EHR, it’s a small percentage. I’d like to see more audiologists and SLPs screen and refer, that would help get the patients to their physicians much sooner for diagnosis and treatment. Dr. Beck: Any thoughts as to why the EHR numbers are so small? Dr. Galvin: Most of medicine is consumer driven. As such, the doctor doesn’t look for everything unless the patient (or family member) complains about a problem. And as you know, Doug, The U.S. Preventive Services Task Force (USPSTF) in December of 2020 said more research is needed before they can make a recommendation to screen or not to screen for dementia. Dr. Beck: I don’t want to get political, but in 2021 they said pretty much the same thing about screening hearing loss in older adults, which is, in my opinion, ridiculous. Dr. Galvin: Yes, but they do drive and influence clinical decision making and ultimately payments and reimbursements for the same. It’s an interesting situation. Dr. Beck: Jim, I recall some 40 years ago when I was doing a pediatric rotation, a wise pediatric otolaryngologist said to the class, something like, “When the mom tells you there’s something wrong with her child, there is almost always something wrong. However, YOU (we were all graduate students) may not be smart enough to figure out what the problem is!” That certainly gave us all pause! So then, regarding MCI, dementia, and cognitive disorders, when the loved one/significant other/carer says something is wrong with mom/dad/whomever, is there usually something wrong? Dr. Galvin: Yes. Almost always. The loved-one recognizing a problem is almost always a more sensitive measure than the physician or the patient themselves recognizing the problem. The person who lives with the patient every day is going to have many more observations across more situations, and so they are more likely to see and notice the unusual activity or event, how the patient may be changing, and how that change interferes with their everyday activities. The physician is trying to make decisions based on a snapshot in time, and often the patient won’t notice a deficit as it may come on very slowly over months or years, particularly if the patient doesn’t complain about it. As I mentioned, much of practice of medicine is consumer driven. When you see your PCP, the first question the doctor asks is usually along the lines of “How have you been since your last visit?” This is the time for the patient to speak about their existing problems and bring up new ones. Dr. Beck: And the observed problems or deficits we’re speaking of are Activities of Daily Living (ADLs) such as the ability to dress, groom, bathe, drive, feed yourself, toilet yourself, things like that? Dr. Galvin: Yes. Those are some of the basic ADL concerns, but those complaints are generally associated with more advanced disease—PCPs are less likely to miss these things. In early stages, the first things that are noticed are in other complicated instrumental activities of daily living such as managing bills, checkbooks, banking, cooking, and cleaning, and using household appliances. These are all areas where deficits might appear, as the patient loses functional independence and these are often observed by the loved one first. These will not be apparent on physical exam so the PCP really needs someone to tell them about these changes—either the patient, or more commonly a family member. As ADLs become more difficult for the individual, they change from the MCI stage into the early dementia stage, as they lose functional independence, and they need other people to take care of more things. Dr. Beck: I’m curious to get your thoughts on the 12 potentially modifiable risk factors for dementia identified by Dr Livingston and colleagues in the 2020 Lancet? For those unfamiliar with the study, the report indicated that 60% of dementia risk is due to aging and DNA, and the other 40% may be due to 12 potentially modifiable risk factors; less education, untreated hypertension, untreated hearing impairment, smoking, obesity, depression, physical inactivity, diabetes, low social contact, excessive alcohol consumption, traumatic brain injury, and air pollution (https://doi.org/10.1016/S0140-6736(20)30367-6). As most of us know, untreated hearing loss was the most significant of the potentially modifiable risk factors. However, I was surprised that untreated visual loss didn’t make the list, as there are many articles indicating that dual sensory loss (hearing and vision) can significantly impact cognitive health. Nianogo and colleagues (2022) published their review of almost 400 thousand people in JAMA (JAMA Neurol. 2022;79(6):584-591. https://doi:10.1001/jamaneurol.2022.0976) in which they identified the three most prominently modifiable risk factors as midlife obesity, physical inactivity, and low education. Of course, these two studies overlap in many respects, but hearing loss didn’t show up as the largest potentially modifiable risk factor in the 2022 study, and vision wasn’t in the 2020 study. Your thoughts, please? Dr. Galvin: Those of us in academics and clinical science always must examine the literature carefully to determine which parts we embrace and which parts we may not. The two studies you mentioned are both well respected and well documented, but they have slightly different conclusions. Then again, they studied different populations at different times, in different cities and more, so I think they both have a lot of very solid take-aways. Nonetheless, there are other risk factors not on the list of 12 which are important, and there are some which are on the list that are not as important. And so all of this is useful, and it seems more than obvious that there is a connection between untreated sensorineural hearing loss and cognition. Regarding visual loss, primary retinal disease seems to potentially impact cognitive issues, but I haven’t read as much regarding front of the eye correlations (e.g., cataracts, scleritis) with cognitive issues. Yet, any sensory loss has the potential to heighten cognitive problems, even if those specific problems are not the actual cause of the cognitive problem. If you cannot see, hear, smell, taste, or feel, those sensory problems will make your overall situation worse. Dr. Beck: Thanks, Jim. I absolutely appreciate your time and vast knowledge on these issues. Let’s do this again next month and we’ll get into the pharmaceutical options recently approved by the FDA regarding realistic expectations and outcomes. Dr. Galvin: Thanks, Doug. Always nice to work with you. Thoughts on something you read here? Write to us at [email protected].